This is one finding shared in a report from the Pakistan Technical Advisory Group (TAG) on Poliomyelitis Eradication, which met in Islamabad from November 27-28 2013. The objectives of the meeting were to: review progress towards poliomyelitis eradication in Pakistan since the last TAG meeting in December 2012, discuss activities planned for 2014 (in particular, planning for the forthcoming low transmission season), and make recommendations to address the constraints facing Pakistan on the way to achieving the goal of eradication. Though there are challenges, the TAG believes that poliovirus can be eradicated from Pakistan, provided that solutions are found for immunising children in currently inaccessible areas.

The context, in brief: The number of cases in 2013 (at the time of this meeting) had already overtaken the total number of cases reported in 2012, making Pakistan the only one of the three remaining endemic countries to experience an increase of cases in 2013. "Violence against vaccinators and their security escorts has created a climate of threat and uncertainty....There remains a significant risk that poliovirus will continue to move into polio-free areas within Pakistan and beyond."

"Despite an environment that is hostile to vaccination in some areas of Pakistan, the communication programme has made advances in creating an enabling environment. A highly engaged media generated over 6,400 national articles focusing on polio in 2013; the highest market share globally. Among these, less than 5% of Urdu and English press portrayed the programme negatively. Caregiver refusal rates were reduced by over 40% in one year, and the proportion of these due to religious reasons reduced particularly in KP [Khyber Pakhtunkhwa], where there was a large focus on religious advocacy. Acceptance of polio immunization in the general community is higher than it has ever been, with less than 0.5% of caregivers refusing the vaccine. Political, social, and religious leaders and groups have become more active and visible supporters of the eradication goal."

Recent developments have required a shift in communication strategy. Previously, a high-visibility approach focused on public information about polio through media and door-to-door social mobilisation. Then, the communications approach moved to indirect methods, focusing on raising awareness about vaccine-preventable diseases and promoting polio vaccination within a wider context of immunisation.

"With over 80% of polio cases originating from only four Pashtun tribes, the communications effort in 2014 must focus more intensively on building trust for immunization services among these highest risk groups. The programme must ensure adequate representation of these groups in as vaccinators, social mobilizers and community influencers, and in mass media messaging." Specific recommendations are outlined in the report. One focus area involves engaging communities and building demand:

"A strategic, consistent campaign to profile vaccinators and frontline workers as protectors of children should be developed and launched as soon as possible.

A Civil Society Coalition that creates a participatory and independent social movement for polio eradication should be build, with particular emphasis on private sector, private practitioners and potential alternative service providers.

Pashtun voices should be amplified in the national and local media discourse to increase local ownership for immunization.

Concrete steps should be taken to expand COMNet's [the Communication Network for Polio Eradication's] capacity to reach unavailable children; and the proportion of children converted from missed due to child not available to vaccinated, should be added as a key performance indicator of vaccination teams where COMNet staff are working. The programme should also find ways to effectively address refusals and 'not available' children in areas where COMNet is not present.

In areas that remain inaccessible to polio teams, the social mobilization network should utilize its local staff to map potential opportunities to reach children through alternative mechanisms: through stocking health facilities with vaccine and promoting routine services, mapping of midwives or other trusted health workers that have access to children, and more robust strategies to reach children during migration.

GPEI [Global Polio Eradication Initiative] protocols for joint micro-planning should be implemented and monitored...to ensure high-risk children are consistently included in micro-plans.

A communication strategy and localized plans should be established to: Reach children in inaccessible areas and support activities should access be achieved; support the SIAD [short interval additional dose] strategy; and support the introduction of IPV [inactivated polio vaccine]."

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